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Prostate Cancer
Dr. Stormont, prostate cancer is a serious disease and it seems to be happening to a lot of men. Can you give us an overview of the disease?
In the United States, prostate cancer affects about 232,000 new men every year, making it the most common cancer detected in American men today. No one is sure why it occurs. But the good news is that there have been many changes and improvements in screening, prevention and treatment and now the death rate from prostate cancer has been decreasing for the past 10 years!
Stillwater Medical Group and Lakeview Hospital have the physician expertise and state of the art technology for early detection, prevention and minimally invasive treatments locally -- of even the most complex cases of prostate cancer.
That’s good to know! So what we’ve heard all these years is true: early detection is the key.
Absolutely! Prostate cancer, like other malignancies, if found early, is smaller and less likely to have spread to surrounding organs, and thus is more easily and successfully treated. This is why screening seems so important to many doctors and patients. Still, not all cancer experts agree that routine screening for prostate cancer is necessary.
That’s surprising. Why not?
Screening may detect slow-growing prostate cancers that will never be a serious threat, yet the treatments, if taken, can result in long-lasting side effects. Men should discuss the pros and cons of screening with their doctors and decide whether screening is best for them.
What kinds of screening tests are done?
Most doctors rely on 2 screening tests -- a digital exam and a PSA blood test (Prostate Specific Antigen). Because neither test is 100% accurate, usually the two are best done together. Because the prostate gland lies in front of the rectum, doctors use the digital exam -- a 5 second test – to detect any enlargement, nodule or firm areas that might indicate cancer. The prostate normally produces a protein called PSA, which increases with non-cancerous enlargement of the gland. It is also elevated if there is a urinary tract infection.
In general, however, the higher the PSA level, the greater the chance there will be prostate cancer. For a PSA of 4, the chance of cancer is about 25%; for a PSA approaching 10, the chance is 50%. Also, the PSA velocity, or rate of rise, is important.
How often should men have these tests?
According to the American Cancer Society, doctors should offer a digital rectal exam and PSA blood test yearly to men age 50 and older, who have a 10-year life expectancy. Some men, such as those with first degree relatives (meaning a father or brother) who have prostate cancer, and African Americans, should be screened at age 40 to 45.
What happens when either or both of those tests indicate some something might be wrong?
Abnormal results of PSA testing or a digital exam may indicate the need for a trans-rectal ultrasound and biopsy of the prostate. This is the only way to diagnose early prostate cancer. This is done in the office, using a local anesthetic. It’s a 5-minute procedure where the prostate is scanned and small tissue samples are removed. Within 2-3 days the results are obtained by having 2 specially trained pathologists independently review the tissue.
Are there specific risk factors for prostate cancer?
Yes, many of them. Besides an elevated PSA, other risk factors include getting older, being African American, and having a family history of prostate cancer. Calculators, such as the one we have developed for our patients, can help to determine risk.
Is there anything a man can do to lower his risk of developing prostate cancer?
Yes! While most risk factors can’t be changed, there are steps men can take to reduce the chances of developing prostate cancer. There is a strong association between a “heart healthy” lifestyle and the development of prostate cancer. Obesity, lack of exercise and a diet high in red meats are all independently associated with either a higher risk of prostate cancer or a more aggressive form.
Conversely, staying fit and eating a lot of fish is associated with a decreased risk. Additionally, green tea, lycopenes, selenium, omega-3 fatty acids and soy have been associated with a lower rate of prostate cancer. More studies are being done to define the role of these supplements and the prevention of prostate cancer.
Okay, what if the worst happens and a man is diagnosed with cancer?
First, the cancer has to staged, or determined if it has spread. Sometimes X-rays are required for this. After this, the patient has to determine if and how he is going to treat his cancer. At this point it can get very confusing, as men can be bombarded with information and medical marketing from doctors, clinics and web sites over what is the “best treatment” for them. So it’s important that a patient adopt a consumerist approach, cross referencing information until he feels he and his doctor have considered all options. Still, it can be difficult for men because many tumors grow so slowly that they are not life threatening, yet treatments can have side effects and generally do affect the quality of a man’s life in some way - mainly erectile dysfunction (ED) and sometimes urinary leakage. For this reason more men are choosing what we call “active surveillance” -- just watching the tumor with a combination of PSA tests and repeat biopsies. If the cancer appears to be actively growing, then treatment can be initiated. If that’s not a feasible choice, there are a number of treatments available. They all have varying side effects and recovery times, but - and this is a key point - all have generally similar cancer control rates especially for the less aggressive forms of prostate cancer. Given our current data and research, overall there is no clearly superior one treatment for most cases of early prostate cancer.
I didn’t realize the patient had so much input into his treatment plan. I assumed it was all up to the doctor.
It seems clear that not only the treatment is of key importance to a good outcome – so is the experience of the treating physician. I give a booklet of current literature with references, encourage reading from outside sources, and have a family conference, inviting second opinions if they’ll help, before recommending treatment.
Is surgical removal of the entire prostate usually the best treatment?
Not necessarily - in fact, most men I diagnose with prostate cancer prefer a less invasive therapy. However, surgical removal of the prostate, or Radical Prostatectomy (RP), is a popular treatment and for some men most appropriate. RP is done either “open,” which is what we all know as the traditional method of surgery, or robotically. There are a lot of similarities between these two methods -- both require a general anesthetic, hospitalization, incisions (one 7” for open and six 1-3” for robotic), and foley catheters. Both have about the same postoperative pain, the same low transfusion rate, erectile dysfunction (ED) and urinary leakage with about a month’s recovery.
Robotic RP results in a shorter hospital stay by about a day, but the procedure does take longer and involves deeper insertion of the robotic “arms” which can rarely result in more serious intraoperative injuries not seen with traditional RP. Also, studies strongly suggest for more aggressive prostate cancers, there is a higher rate of residual disease with robotic.
Are there less radical options?
Absolutely. Not all prostate cancer needs to be removed with an incision. In fact, most of my patients, if appropriate candidates, prefer a Minimally invasive prostate cancer procedure-such as Cryoablation or Radiactive Seeds. Both are less invasive than RP with a quicker recovery and less chance of urinary leakage than RP. They are done with either a spinal or general anesthetic, as an outpatient or at most an overnight stay. Most importantly, for many prostate cancers, their cancer control is equivalent to RP.
Freezing (technically known as Cryoablation) is a technique that treats prostate cancer by lowering the temperature within the prostate, using needles to infuse a very cold gas directly into the gland. Return to most normal activities takes about 2 weeks.
Radioactive seeds (also known as brachytherapy) is a method where radioactive pellets are implanted through needles into the prostate. The recovery time is also rapid, and most patients can get back to normal activities within a few days. While both are less invasive alternatives to RP, they can cause ED and do require brief periods of catheterization.
I don’t know, Dr. Stormont. Incisions or needles? Both sound pretty scary.
I understand, and as mentioned, not any one treatment is the best for all men. There are some other, even less invasive alternatives. Hormonal therapy, usually with a injection every 4 months, reduces the testosterone levels, thus slowing down the cancer. It can be very effective, but is temporary. External Beam Radiation is another treatment that is safe and effective, but it requires about 8 weeks of treatment, and a patient would have to travel to the cities to get it.
There are newer treatments on the horizon, including HIFU (which stands for High Intensity Focused Ultrasound) a ‘no touch’ method that currently still considered experimental in the US. It is only available abroad, but will probably be FDA approved, covered by insurance and available in the US after 2010.
Speaking of insurance, is treatment generally covered?
All treatments are covered by Medicare and insurance, and most can be done locally in Stillwater. Men should remember that this is only a brief overview of a very complex problem, and each patient requires individualization of his treatment. With their doctor’s guidance, men can evaluate their own situation and determine which treatment is right for them.
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